EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS The following agencies are acknowledged for their contribution in the development of the referral pathways. iehealth Inner East Community Health This project received funding from the Commonwealth and Victorian Governments.
CONTENTS EXECUTIVE SUMMARY 2 SCOPE OF PRACTICE 3 Acute and Emergency Department OT 3 Sub-Acute OT 3 Ambulatory Care OT 4 Community Health Services OT 4 GUIDELINES FOR SWEP APPLICATIONS 5 REFERRAL TOOLS 7 From Acute Inpatient Occupational Therapy 7 From Acute Inpatient OT Requiring Pressure Care Follow up 8 From Sub-Acute Inpatient OT for Equipment Needs 9 From Sub-Acute Inpatient OT for Home Modification Needs 10 From Ambulatory Care OT for Equipment Needs 11 From Ambulatory Care OT for Home Modifications 12 EXECUTIVE SUMMARY The Eastern Metropolitan Region (EMR) Occupational Therapy (OT) Referral Pathway Project was initiated by Manningham Community Health Services Ltd (MCHSL) on behalf of all partner agencies, in mid-2012. The goal of this project is to improve client outcomes through the establishment of standardised referral pathways for Occupational Therapy within the Eastern Metropolitan Region. The following partner agencies collaborated on the project: EACH Eastern Health Inner East Community Health Service Inspiro Community Health Service Knox Community Health Service Manningham Community Health Service Monashlink Community Health Service Whitehorse Community Health Service Yarra Valley Community Health Service Royal District Nursing Service District Nursing Service Scope of Practice for OTs within each sector was defined: Acute and Emergency Department OT Scope of Practice Sub-Acute OT Scope of Practice Ambulatory Care OT Scope of Practice Community Health Service OT Scope of Practice 2 The Working Group developed six (6) referral pathways, which include: EMR acute patient OT for equipment and home modification needs EMR acute patient OT for pressure care EMR sub-acute patient OT for equipment needs EMR sub-acute patient OT for home modification needs EMR ambulatory care OT for equipment needs EMR ambulatory care OT for home modifications All partners remain dedicated to this project and MCHSL will continue convening the Working Group to ensure the ongoing review of the pathways for compliance, relevance and evaluation of impact to client outcomes. Jenny Jackson MCHSL Chief Executive Officer August 2013 For an electronic copy go to: www.mannchs.org.au/publications.php
SCOPE OF PRACTICE Acute and Emergency Department OT Sub-Acute OT Occupational Therapists (OTs) working in the acute hospital environment, facilitate discharge within the context of the acute reason for hospital admission. Patients are commonly admitted to the acute hospital with chronic or pre-existing medical conditions, however the acute OT may not be referred to assess these patients, particularly if their conditions are not directly related to the reason for hospital admission or have not caused an acute change in functional status. Therefore it cannot be assumed that acute hospital admission will result in automatic OT intervention. The role of the acute OT is to ensure the patient is appropriate for discharge; within this scope of practice the acute OT may prescribe low cost items of equipment and assess for low cost home modifications (under $1000) if they will prevent hospital re-admission or assist in facilitating home discharge. Patients are provided with equipment for 30 days post discharge and/or encouraged to purchase low cost items should they require them (i.e. they present with long-term needs). As a result, OTs working in Emergency Departments and acute hospital wards rarely apply for SWEP funding. On the occasion when a patient cannot afford a low cost item of equipment and the ongoing need (post 30 days) is obvious, then the acute OT will complete the SWEP application. Acute OTs will prescribe and provide pressure care equipment (cushions and mattresses) that are assessed as suitable to manage the pressure injury at the time of discharge from the acute hospital setting. Equipment will be trialed on the acute ward and funded for 30 days post discharge. Acute OTs will collaborate with nursing staff to initiate a referral to community nursing (RDNS or Eastern at Home) for wound care. Acute OTs will liaise with the community nursing service regarding equipment prescription and recommendations for ongoing care at the time of discharge. Community nursing will monitor wound healing and refer to Community Health OTs should the pressure injury require long term equipment prescription. Occupational Therapists in the acute setting will refer to Community Health Centre OTs for assessment of long term items of equipment when: The patient s level of occupational performance is not stable on discharge. The patient does not have goals that indicate referral to the Eastern Health Community Rehabilitation Program (CRP) but has high cost and/or complex equipment and/or home modification needs. A trial of multiple different models for an item of equipment is required. Multiple home assessments are required to trial items of equipment and/or assess for permanent home modifications. Patients may be admitted to Sub-Acute following an acute admission. They are often neurological or orthopedic patients. All patients are assessed by an OT. Due to reduced length of stay, inpatient rehabilitation goals usually surround the bare essential occupations that a patient needs to be able to perform on discharge. Unfortunately equipment issued on discharge is limited to available hire stock, therefore patients are often sent home with the available, adequate item rather than the perfect model of equipment. Patients are often referred on to community services (i.e. Personal Care Assistance, Home Help) for tasks that they do not achieve independence with on the ward. Often these patients are also referred onto CRP to progress independence in these areas if their condition is likely to improve with the potential goal of reducing services required. Examples of common sub-acute goals include: Independent self care Independent drink and light meal preparation Adequate home setup for occupational performance needs on discharge Independent implementation of energy conservation strategies Independent implementation of falls prevention strategies Occasionally SWEP applications are completed in sub-acute. Patients are mainly encouraged to purchase equipment if their occupational performance is unlikely to improve post discharge and they require low cost items on a permanent basis. In instances where major modifications are required to facilitate discharge from hospital, and are to be funded by patient/family, the inpatient therapist would make their recommendations and arrange for Archicentre plans. The OT may then arrange quotes (or family may pursue quotes) from a registered builder who may then follow through with completion of these works. In instances where the patient s level of functioning may change or is unclear, temporary equipment or minor modifications may be recommended by the inpatient therapist rather than more major modifications. Any future modifications would then be followed through in the community when long-term functional status is clearer. In instances where major modifications are requested, but not required to facilitate safe discharge, and the patient/family wish to fund modifications, the OT may refer on to Community Health to follow this through. As with acute, higher cost items that are generally required by patients with more complex needs may not have a SWEP application completed on the ward due to: the patient s level of occupational performance is not stable on discharge; inability to trial different models of equipment; need to trial different models of equipment in patient s home/usual environment; need to complete multiple home assessments These patients will be referred onto ambulatory care if they have rehab needs, or Community Health to determine long term equipment needs. Sub-acute OTs may refer to both Ambulatory Care and Community Health if the patient requires major home modifications (over $1000) funded through SWEP. EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS l 3
SCOPE OF PRACTICE CONTINUED Ambulatory Care OT Community Health Services OT Ambulatory Care OTs provide treatment to clients within their own home. Length of stay is approximately 6 12 weeks. In order to be eligible a client must satisfy the following criteria: Have rehabilitation goals (time limited, functional) The reason for referral to Occupational Therapy services to address equipment and/or modification needs must be related to the reason for admission for rehabilitation. If they fail to meet the criteria for rehabilitation they will be referred to Community Health or private Occupational Therapy services for ongoing input. Community Rehabilitation Occupational Therapists will: Provide equipment and minor home modifications where the need for OT input relates to the reason for admission (i.e installation of a rail at the front access to enable community access for a client who has had a recent hip replacement). Submit SWEP applications for eligible clients when the equipment or home modification does not require OT sign off (i.e under $1000) when funding becomes available. Consider provision of equipment/modifications over the cost of $1000 if the client is willing to purchase/pay upfront and it is evident that equipment will be provided/work will be completed within the estimated length of stay of the CRP admission and not delay discharge. Consider whether referral to a private OT for follow up may better suit the client with use of a GP Allied Health care plan. Community Rehabilitation OTs will not: Accept equipment only referrals when no other discipline is involved, as all CRP eligible clients must have interdisciplinary rehabilitation goals. These referrals will be directed back to the referrer to refer onto the appropriate Community Health Service. If another discipline is involved, OT will accept a referral for equipment provision, provided it meets the criteria set out above for interventions relating to equipment provision. Start a SWEP application for major bathroom modifications/ equipment prescription over $1000 for an admitted client and refer onto Community Health. These clients should be referred directly onto Community Health either at the acute/ Sub-Acute stage or during the CRP admission depending upon satisfaction of CRP criteria above. Concurrent referrals to Community Health and Community Rehabilitation OTs will be accepted to enable rehabilitation goals to be pursued as well as major home modifications/costly equipment. Accept referrals for driving assessment or referral onto driving services only. Occupational Therapy services provided by Community Health Services are guided by the Home and Community Care Priority Guidelines produced by the Department of Health. Through discussions held between Community Health and Eastern Health, Community Health OTs have also agreed to the following. Community Health Occupational Therapists will: Accept referrals for major bathroom modifications/ equipment costs over $1000 where SWEP application and sign off is required for funding and length of application time will exceed length of CRP admission. Accept concurrent referrals whilst CRP OT is involved where the above conditions apply, when the client is safe and set up to manage care at home while awaiting input for more permanent modifications/equipment. Where able, consideration will be given to joint sessions for handover to enable continuity of service appropriate to client need. Accept referrals from any allied health discipline either at acute, sub-acute or ambulatory level that meets Community Health OT acceptance criteria. Community Health OTs will not: Accept referrals to sign off on SWEP applications that have been previously submitted by Eastern Health OTs. Accept referrals when equipment requires maintenance and checkup post prescription. Accept referrals for home modifications/equipment that is required for a safe discharge. Accept referrals to complete a SWEP application for a low cost item of equipment. 4
GUIDELINES FOR SWEP APPLICATIONS This Table should be used as a guide, with consideration given to individual patients on a case by case basis. Occupational Therapists in Eastern Health will only complete State Wide Equipment Prescription (SWEP) applications if the patient s occupational performance issues are stable and the permanent need for the item of equipment is obvious. The Community Health Services column refers to referrals sent from Eastern Health. Acute & ED Sub-Acute Ambulatory Care Community Health Toileting Equipment Over Toilet Frame Bedside Commode Transporter Commode Referral accepted from acute only Self-Propel Commode If doesn t require SWEP sign off Bathing Equipment Shower Stool Bathboard Transfer Bench If OT home visit completed Bath Hoist Seating Equipment Low Back Chair High Back Chair Electric Lift Chair If OT home visit completed If OT home visit completed Wheelchairs Transit/Carer Wheelchair Manual Self-Propel Wheelchair Power Wheelchair Often these referrals are for chronic needs No customisation Clients needs not complex Need for multiple models to be trialled within home/community. Client condition not stable and best model cushion not certain. Scooter Need for multiple models to be trialed within home/community. Best model cushion not certain EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS l 5
GUIDELINES FOR SWEP APPLICATIONS CONTINUED Acute & ED Sub-Acute Ambulatory Care Community Health Pressure Care Pressure Care Cushion For Transit Wheelchair For items under $1,000 that don t need sign off If wound is long term and stable No customisation required Clients needs not complex If referral is for pressure care only with no other discipline involvement - refer to CH For customized cushions only Pressure Care Cushion For Self Propel / Power Wheelchair Complex pressure care needs. Need for multiple models to be trialed within home/community Pressure Mattress Bed Equipment Cot Sides Self Help Poles Hospital Bed Referral accepted from acute only Referral accepted from acute only Portable Ramps Small Ramps to Access Home permanent need for ramp obvious Ramps for Community Access OTs to consider if long term need is clear, client can pay gap and hire equipment trialled/loaned is suitable i.e multiple trials not required. Then Eastern Health OTs to consider SWEP application due to high expense of hiring Only if item is under $1,000 and doesn t need sign off Home Modification Shower Rail Toilet Rail Banister Rail essential for access in/out of home Complex Banister Rail (bends and pathways) If OT home visit completed If OT home visit completed Platform Chair Raiser Referral accepted from acute only Hand Held Shower Hose Major Bathroom Modification 6
REFERRAL TOOLS From Acute Inpatient Occupational Therapy Presenting Issue: Patient admitted to Eastern Health Acute Hospital with a plan for home discharge Equipment Required Is Home Assessment indicated to facilitate safe home discharge? Provide equipment 30 days post discharge for hire +/- Provide details and encourage patient to purchase low cost items Prescribe basic hand/bannister rails Prescribe equipment that facilitates home discharge from acute setting Is funding an issue? Refer to handyman for equipment installation Provide equipment 30 days post discharge for hire +/- Provide details and encourage patient to purchase low cost items Complete SWEP paperwork for basic handrails/equipment (see Table). Refer to Community Health Centre OT if complex modifications/equipment required (SWEP application not commenced) Does the patient require ongoing OT input Discharge from OT If rehab goals identified Refer to CRP when: Complex home modifications required High cost item existing item requires review Trial of high cost items is required Joint referral can be completed to CRP/CHS ensure both parties are aware of concurrent referral EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS l 7
REFERRAL TOOLS CONTINUED From Acute Inpatient OT Requiring Pressure Care Follow up Presenting Issue: Patient admitted to Eastern Health Acute Hospital with a plan for home discharge Management of Pressure Area Is pressure care required? (cushion/mattress) Discharge from OT if no other issues Hire equipment 30 days post discharge and provide details if ongoing hire required Refer to RDNS/Eastern at Home/District Nursing for ongoing monitoring if required Refer directly to CHS if no monitoring required and client s existing item of equipment needs to be replaced ( e.g worn) RDNS/Eastern at Home/District Nursing to refer to CHS if pressure area requires long term equipment prescribed 8
From Sub-Acute Inpatient OT for Equipment Needs Presenting Issue: Patient admitted to Eastern Health Sub-Acute setting with plan for home discharge. If Condition is not stable and OT is unsure of long term requirements refer directly to CHS Equipment required for discharge See Table for items covered Is the equipment required long term Client discharged with hire equipment for 30 days with details of how to continue/ purchase if required If ongoing pressure care is an issue refer to RDNS/ District Nursing for monitoring. RDNS to refer to CHS as required Is trial of equipment necessary? Is the hire stock equipment suitable? Is client able to purchase? Arrange hire equipment plus determine how to obtain equipment long term Does the client have ongoing rehab goals? OT to organise equipment for purchase Is equipment within SWEP funding limit/ client able to pay excess? Complete SWEP application Refer to CRP Refer to CRP Include review of more appropriate equipment see Table for items covered Include review of more appropriate equipment see Table for items covered Joint referral can be completed to CRP/CHS ensure both parties are aware of concurrent referral EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS l 9
REFERRAL TOOLS CONTINUED From Sub-Acute Inpatient OT for Home Modification Needs Presenting Issue: Patient admitted to Eastern Health Sub-Acute Hospital with plan for home discharge Home assessment completed Modifications required (< 2visits) Major modifications required Complex bathroom modifications Ramps Complex step modifications Archicentre report/sign off required Minor modifications required under $1,000 (See Table) Handrails Simple step modifications Simple bannister rails Is modification required for safe discharge? Is funding an issue? Can client fully self fund? Is equipment within SWEP funding limit/ client able to pay excess? Sub-Acute OT to organise Refer to builder/ handyman service Complete SWEP application OT to organise temporary set up/ alternate discharge destination 10
From Ambulatory Care OT for Equipment Needs Presenting Issue: Patient admitted to Eastern Health Ambulatory Care setting with plan for discharge Ambulatory Care (Community Rehabilitation) Referrals accepted for patients with ongoing rehabilitation needs See Table for items covered Is the equipment required long term? Client discharged with hire equipment for 30 days with details of how to continue/ purchase if required If ongoing pressure care is an issue refer to RDNS/ District Nursing for monitoring. RDNS to refer to CHS as required Does the equipment cost less than $1000? OT to organize equipment for purchase Is client able to purchase? Is equipment within SWEP funding limit/ client able to pay excess? Complete SWEP application EASTERN METROPOLITAN REGION OCCUPATIONAL THERAPY REFERRAL PATHWAYS l 11
REFERRAL TOOLS CONTINUED From Ambulatory Care OT for Home Modifications Presenting Issue: Patient admitted to Eastern Health Ambulatory Care with plan for discharge Ambulatory Care (Community Rehabilitation) Referrals accepted for patients with ongoing rehabilitation needs Major modifications required Complex bathroom modifications Ramps Complex step modifications Archicentre report/sign off required Minor modifications required under $1,000 (See Table) Handrails Simple step modifications Simple bannister rails Is funding an issue? Is equipment within SWEP funding limit/ client able to pay excess? Refer to builder/ handyman service Complete SWEP application 12